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Schultz, Aaron R���i1�E� �UL �7 '`'�`� �,u�.D CI�"Y �L�RK NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesata State Statute 466.05 states that"...cvery person...who claim.s damages from m�y municipaTiry...,s�rall cause to be prestnted to the goyernyg body of the manicipaliry within 180 days Q/ter the aTkged lass ar injury is drscovered a notice statvig die t�►ee,Piace.and circum.stancas thereof,ancl tlu amowu of compensation or other nlief demanded" PleaAe complete this form in its entirety by ckarly ty]i�►g or printing your answer to esch question. If more space is needed,attach additional s6eets. Pleese note that you an11 not be contacted by telephone to darify answers,so provide as mnch information as nece,9sary to explair►yonr claim,and the amoant of compensation being recNested. Yoa will receive a written aclawwledgement once your form is received. The proccss can leke aP to ten weeka or longer depending on the nature of your daim. 'I7�is form mast be signed,and boW pages completed. If someW6�g does not aPP�Y�write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, , 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102 �r�yr�S�S��� 1���I�(.� InS. AIS/i: �Chv'���7 First Name 1�rl r�n _ Middle Initial Last Name Company or$usiness Name Are You an Insurance Company Yesy No If Yes,Claim Number? �. `f - 3`,� ���1� �` StreetAddress �� � �� — � ���� City��:.5�.�1J'l;� S � State�1� 7ip Code �I UC`�I�C����l Daylime Phone(`7�v) ��V- �Z�C�ll Phone(� - Evening Telephone�_) - Date of Accidend Injury or Date Discovered I���7�/�� Time 3 '�� am,� Please state,in detail,what occurretl(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ' l' /„ Please check the box(es)that most closely repnesent the reason for completing this form: �My vehicle was damaged in an accident ❑My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow �My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property �Other type of property damage—please specify �Other type of injury—please specify In order to process your claim yon nced to include wnies of all applicable docurnents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitUing your claim form. O Property damage claims to a vehicle:two estimates for the repairs to yow vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims:legible copies of any ticket issued and a capy of tt�e impound lot receipt O Other property damage claims:two repair estimates if the clamage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims:medical bills,receipts O Photographs aze always welcome to document and support your claim but will not be returned. Page 1 of 2—Please comglete and return both pages oP Claim Form Failure to complete and return both gages wII1 result in delay in the handling of pour claim. All Claims—ulease comulete this sechion Were there witnesses to the i�ident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: � Were the police or law enforcement called? _ es' No Unknown (circle) If yes,what department or agency? � i� � Case#or report# I y��li,�,�,��� Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as ossible. If necessary,attach a diagram, � '�i 5 f"(i S`1" �S�- I�CL�'� �X ►'t" Please indicate the amount y are seeking in compensation or what you would like the Caty to do to resolve this claim to your satisfaction. ����3�� �1/ Vehicle Claims—ulease c�om lete this section ❑c k box if this section dces not a 1 Your Vehicle: Year 3C�1�l Make � 61, Model �t �j� l, License Plate Number State Color Regi stered Owner��(f'�u(1 [:.f i i:i t Z- Driver of Vehicle ' Area Damage�d - �' ° City Vehicle: Year .�,%'1�Make Y �� Model I ►�n n�� j� License Plate Number 7f v�.1 f� � State�'' Color [�1�+"� Driver of Vehicle(Ci F�nployee's Name)f�r�1?��y,it h �-^-� Area Damaged�C�i'1� Iniur�Claims—please complete this secl3on �l�check box if this section dces not annlv How were you injured? What part(s}of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive tream�ent7 (provide date(s}) Natne of Medical Provider(s}: Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s}} Name of your Employer: Address Telephone ❑Check here if you are attaching more pages to this claim form. Number of additional gages By signing this forny you are stating that adt informatiori you have provrded�s true and correct to the best of your kraowdedge. Unsigned forms will not be processed Submitting a false claim can result in prosecrction. Date fo mpleted � � � Print the Name of the Person who Completed ' o l� �D� ��G �� °� Signature of Penson Making the Claim: s�� � xevised Febru�y 2011 � � Our narned insured's 2014 Volkswagen Passat was traveling on I-35 east. A City of St Paul 2010 Chevrolet Irnpala, license plate#767JHB, was traveling on I-35 east. As our insured's vehicle stopped due to traffic, the 2010 Chevrolet Irnpala rear-ended a 2010 Ford F-150,which rear-ended our insured's vehicle. The driver, Bobby Donahue, is the proximate cause of the accident for following too closely. �/�i��������+/� Payment Address Document Address 24344 Network Place P.O. Box 512929 Chicago, IL 6Q673-1243 Los Angeles, Ca 90051 Phone:(877)818-0139 Fax: (888)781-6947 7/1/2015 10:39:00 AM Certified Mail 91 7199 9991 7035 3566 4814 Return Receipt Requested CITY OF ST PAUL CITY CLERK OFFICE 310 CITY HALL 15 WEST KELLOGG BLVD ST PAUL MN 55102 Your Client: DONAHUE, BOBBY Your Claim Nurnber:N/A Our Insured:SCHULTZ, AARON Our Claim Number:l4-3448436 Arnount Subject to Reirnbursernent:838.11 Arnount of Insured's Deductible:WAIVED Please take this as forrnal notice of our subrogation rights relative to the above -captioned clairn. We have completed our investigation into the facts of the above-captioned loss and find that your insured was the proximate cause of the accident. Location of Loss: I-35 EAST/ ST PAUL EXIT IN ST. PAUL Date and Tirne of Loss:10-07-14 AT 3:15PM Description of Loss: Our narned insured's 2014 Volkswagen Passat was traveling on I-35 east. A City of St Paul 2010 Chevrolet Irnpala, license plate#767JHB, was traveling on I-35 east. As our insured's vehicle stopped due to traffic, the 2010 Chevrolet Irnpala rear-ended a 2010 Ford F-150, which rear-ended our insured's vehicle. The driver, Bobby Donahue, is the proximate cause of the accident for following too closely. Please make your draft payable to Progressive Direct Insurance Co as subrogee of "SCHULTZ, AARON °, in the arnount stated above and mail it to the attention of the undersigned at your earliest convenience. All supporting docurnentation is enclosed. I have diaried rny file ahead fifte n (15) days. Thank you for your anticipated, prornpt attention to this rnatter. . �--�'" _. Christopher Woolfolk Subrogation Representative Progressive Direct Insurance Co Tel. 440-910-5505 Fax. 888-781-6947 Ernail: Christopher Woolfolk�,dprogressive.corn Claim 1'avment lletail Y�i��e 1 of�1 �f�i�rs ���ta��€�� ����€� � ���,.��������� °� ;-Payment Information ----------------------------------------------------------------°--------------------------------_____---_______-__----� Disbursement Number: 328177482 Total Amount: $838.11 Draft Number: 2008032963 Invoice Number: 16757568 Pay to the Order of: AARON D SCHULTZ AND LAMETTRYS COLLISION INC Mailing Address: 4700 S ROBERT TRL INVER GROVE HEIGHTS,MN 55077 US In Payment Of: Progressive Invoice Number:16757568 r.�Review�ed Summa ____.___,_.__. ..__._.__ ____ _________ _______ _.___.___ _.__.__._ .-------- .__._..__ _--------._._., ry_____.___.___... Issuing Rep: A093085 Approved By: Issue Date: 04-0&15 Review Date: Last Updated Rep: A093085 Reviewed By: ;--Bank Information ------------------------------------------------__�_----------------------------------------------------------------------------------, Type: LOSS Bank Code: 1CD Stop Reason• Cleared: 04-if'r15 Stop Date: ___.._--- .__,.._ _ _____ _---- ___. _.__ _ ____ ____ ---_.. -Exposure Detail:COLL--------- -- ----- --- ----- - - ----- - -- --- ---- -------- —---------, Party Name: SCHULTZ,AARON D Amount Paid: $838.11 ! Property Description: 14 VOLKSWAGEN PASSAT Deductible Taken: $0.00 Payment Type: FINAL PAYMENT Property Damage: $0.00 Rental: $0.00 http://claiinspayments/Sravo/ClaimsPayments Web/default.aspx?page=ClaimPaymentDetail... 7/1/2015 Date: 417/2015 03:59 PM Estimate ID: 14-3448436-01 Estim�e Version: D Committed Prafile ID: Melro AIIExcept7.125 Progressive Direct Insurance Co Damage Assessed By: CODEY W ITTIG `Claim Rep: Codey W ittig (672)655-1039 ClassiFication: 'Product Type Auro 'Date of Loss: 10/7/2014 'Deductible: 1,000.00 'Claim Number: 14-3448436-01 Insured: AARON SCHULTZ Owner: AARON SCHULTZ Address: 36080�UINLAN AVE,CENTER CITY,MN 55012 Telephone: Home Phone: {651)356-2688 Cell Phone: (651)260 3653 Contact Phone: (851)260-3653 Mitchell Service: 911103 Description: 2014 Volkswagen Passat SE Vehicle Production Date: 3/14 Body Style: 4D Sed Drive Train: 2AL Turbo Inj 4 Cyl 6sl 8A FW D VIN: 1VWBN7A35EC085481 Licvise: 589NEU MN Mileage: 27,525 OEM/ALT: A Search Code: ARDENHILL2 Color: GRAY Optians: PASSENGER AIRBAG,POWER DRIVER SEAT,POW ER LOCK POW ER W INDOW,POW ER STEERING REAR WINDOW DEFOGGER,AIR CONDITIONING,CRUISE CONTROL,TILT STEERING COLUMN AMlFM STEREO,DRIVER AIRBAG,HEATED EXTERIOR MIRROR FRONT SIDE AIRBAG W ITH HEAD PROTECTION,ANTI-LOCK BRAKE SYS.,TRACTION CONTROL ALUM/ALLOY WHEELS,REARVIEW CAMERA,TIRE WRATION/PRESSURE MONITOR NAVIGATION SYSTEM,AUXILIARY INPUT,BLUETOOTH W IRELESS CONNECTIVITY,HD RADIO LEATHER STEERING WHEEL,SATELLITE RADIO,CD P�AYER POW ER ADJUSTABLE EXTERIOR MIRROR,SUN ROOFMIOONROOF,TRIP COMPUTER FIRST ROW BUCKET SEAT,TELEMATIC SYSTEMS,SIDE AIRBAGS,AUTOMATIC HEADLIGHTS SECOND ROW SIDE AIRBAG W ITH HEAD PROTECTfON INTERIOR AUlOMATIC DAY/NIGHT OR ELECTROCHROMATIC MIRROR,MP3 PLAYER DAYTIME RUNNING LIGHTS,DRIVER SEAT W ITH POWER LUMBAR SUPPORT ELEClRONIC STABILITY CONTROL,FRONT HEATED SEATS FRONT SEATS WITH POWER LUMBAR SUPPORT,KEYLESS[NTRY SYSTEM,REAR BENCH SEAT STEERING WHEELAUDIOCONTROLS Line Entry Laba Line Rem Part Typei Dollar Labor kem Numba Type OperaHon Description ParWumber Amourit UnRs _ Reer Bumner 1 BDY OVERHAUL Rear Bumper Cover Assy 3.0 # 2 101662 BDY REMOVE/REP�ACE Rear 8umper Cover Rananufactured 319.00 INC # 3 RE F REFINISH Rear Bumpar Coner C 2.6 4 101666 BDY REMOVE/INSTALL Rear Lwr Bumper Valance Pand EnisGng INC r 5 936012 ADD'LCOST HAZARDOUS WASTE DISPOSAL 3•S� ' ADDITIONAL OPERATIONS 6 REF ADDL OPR Clear Coat ��� Addklonal Costs d�Maierlals 7 ADD'L COST PainUMa4aials 122.40 ` 8 900500 REF' REMOVE/REPLACE FLEX ADDITIVE °Non-OEM 5.00 ' 0.0' *-Judgment ftem #-Labor Note Appl ies "*Non-OEM -Non-Original Equipment Manufacturer Replacement Part C-Included In Clear Coat Calc r-CEG R&R Time Used For This Labor Operation � ESTIMATE RECALL NUMBER: 04I07/2015 15:59:13 14-3446436-01 Mitchell Data Version: OEM: MAR 75 V0403 MAPP:MAR 15 V0405 Copyright(C)1994-2015 MRchell International Page 1 of 4 Sokware Version: 7.1.177 All Rights Reserved Date: 4/7/2015 03:59 PM Estimate ID: 14-3448436-01 Es6m�e Version: 0 Committed ProfilelD: Me[roAllExcept7.t25 KEYSTONE-INS QUALITY PRT 3615 MARSHALL ST.NE MINNEAPOLIS MN 55478 {soo�s2e-ieas �s�2}�es iaes 2 "VW 1100192R 319.00 Al1 manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to. If additional parts or operations are necessary to properly accomplish this, please contact the estimating claims rep. Estimate Totals Add'I �abor Sublet L Labor Subtotals Unrts Rate Amount Amount Totals II. Part Replacement Summary Amount Body 3.0 54.00 0.00 0.00 162.00 Taxable Par[s 324.00 Refinish 3.6 54.00 0.00 C.00 194AC Sales Tax �a 7.125% 23.09 Non-Taxade Labor 356.40 Total Replacemerrt Parts Amount 347.09 Labor Summary 6.6 356.40 III. Additional Costs Amount IV. Adjustments Amount Taxade Costs 122.40 Insurance Dedudide 1,000.00- Sales Tax @ �.725% SJ2 Subtotal of AdJustmenis Exceeds Gross Total Non-Tauable Costs 3.50 Customer ResponsibilRy 838.11- Total Adddional Costs 134.62 Paint M�aial Method:Ratas Init Rate-34.00 L Total Labor: 356.40 II. Totai Replacem�t Parts: 347.09 III. Total Add'Rional Costs: 134.62 Gross Total: 838.11 IV. Total Adjustments: 838.11- Ne[Total: 0.00 PoirA{s)of Impad 6 Rear Center{P) AI4 Location: PROGRESSIVE Inspaction Si[e: LAMETTRY'S COLLISION INVER GROVE HEIGHTS Address: 4700 S Robert Trail Invar Grwe HeigMs,MN 55077 {651)286-3921 Inspection Date: 4i 7I2015 �I ESTIMATE RECALL NUMBER: 04/07/2015 15:59:13 14-3448436-01 Mitchell Data Version: OEM: MAR 75 V0403 MAPP:MAR 15 V0405 Copyright(C)7994-2015 Mitchall Intemational Page 2 of 4 Sokware Varsion: 7.1.177 All F2ights Reserved Date: 4/7/2015 03:59 PM Estimate ID: 74-3449436-01 Estima[e Version: 0 Committed Pro(ile ID: Mdro AIIExcept7.125 THIS IS A DAMZIGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR - BASED ON DAMAGE VISIBZE OR CERTAIN AT THE TIME IT WAS WRITTEN. IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT SHOWN INCLUDES TIME OR ALIAWANCE FOR MEASURING BEFORE, DURING AND AFTER THOSE REPAIRS. THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER CHOICE. TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED DURING THE COURSE OF REPAIRS, CONTACT PROGRESSI�7E FOR SUPPLEMENT HANDI�ING PROCEDURES. PROGRESSIVE HONORS THE PREVAILING LABOR MARKET RATE IN YOUR AREA FOR YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF , PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE DIFFERENCE. LIFETIME GUARANTEE FOR SHEET METAI, AND PLASTIC BODY PARTS The replacement parts written on the estimate are intended to return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in the estimate fails to return your vehicle to its pre-loss condition (assuming proper installation) , in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a , manufacturer's or other warranty. This service will be per£ormed at no co�t to you (including associated repair and rental car costs) . To obtain service under this Guarantee, call Progressive at 1-B00-274-4641. This Guarantee appliea as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle. THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUIIRANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS THAT WIZL RETURN YOUR VEHICLE TO ITS PRE-I,OSS CONDITION. ACCORDINGLY, PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF THESE PARTS. ' Part Type Terms and Abbreviations ', NEW and OEM or part number displayed - These refer to a new, original equipment manufacturer pazt. NON-OEM and A/M and Qual REPL - These refer to an after-market part, which is a new, non-original equipment manufacturer part. USED/RECYCLED and LKQ - Theee refer to a u9ed OEM part. REMANUFACTURED and RECOND, and RECORE - These refer to used/recycled OEM parts that have been refurbished. REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION INCLUDING TOW/STORAGE CHARGES: SHOP SIGNATURE: EST. COMPLETION DATE: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CZAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF ESTIMATE RECALL NUMBER: 04/07l201515:59:13 14-3448436-01 Mitchell Data Version: OEM: MAR 15 V0403 MAPP:MAR 15 V0405 Copyiight{C)Y994-2015 Mitchell Intemationai Page 3 of 4 Sokware Varsion: 7.1.177 All Rights Reserved Date: 4/7/2015 03:59 PM Estimate ID: 14-3448436-01 Estim�e Version: 0 Committed Profile ID: Metro NlExcept7.125 INSURANCE FRAUD. Everd Log Fle Created: 04l07/2015 11:31:21 AM Estimate Started: 04/07l2015 03:58:19 PM Estimate Printed: 04I07/2015 03:59:17 PM Estimate Committed: 04;07/2015 03:59:13 PM Estimate Uploadad: 04l07/2015 03:59:21 PM ESTIMATE RECALL NUMBER: 04/07/2015 15:59:13 14-3448436-01 Mitchell Data Version: OEM: MAR 15 V0403 MAPP:MAR 15 V0405 Copyright{C)1994-2015 Mitchell Intemational Page 4 of 4 Sokware Version: 7.1.177 All Rights Reserved .;�� ' p� S�OZ/L 6/90 :a�eQ pania�a� � 1 � �0 l d ' � t �� / w�o ',24 08280� ;� � �.. I�,�°�°� m.� ..,� � ,M, „�,,, .,,,_ � f �t I � U3 ItlD �D Y lp 7 ..oia ��ue "'S3o � � _ ,.,.,� ,,,�,�, '1 I 35E I I �' ° ��r�seM,� a _�rt Qn�]w«� g WVffiNC I I !M!ilJl MYtlIdCL00'M . . LI LJ WNeevs n6u.�•�e�lt r11 �...�atriNw 52 MAPLES4QOD ��}�0_. 3b0 1D LARPEN9'EUR RnI(�i h101N11 MI16NlL�4M1Ell.l pUff CI� 0.7U*tl lW+TOM C�14a{J�uLHWO�A.i Al.w! LN:: Ple II1L 1 � �1. zo�.62236963i 7 � B o7 61 w27326733231? 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PAUL WES2EI�N NATIONAL CFP1025979 � oJtGO M�i�wr w NRG�lefi• uurrite� ^� � 1!At7GRENT Ii1MOLVEDA CONMEaC1A�qOiC�VpRCLE SCMDO�81�5,01l MEAO START BUS '�"�9 ��°` °� �� ��� (�MCN6E0.TONOTXYTNE$fA7EPATAQt(�puhc�unU�.M316D.7IIr.d1El�51f). .l � � ou*�+cac vti.cu+w 1.uarcee:wMUtew+e I cornwaw cowuereu�vs�pew�eav•�►1�wrno�R... m*r..rc. �� �� I . � . . r�rc m� ww I,�_ ' I un �Ea�m rwt u�e �w.n ..�cc wsw tonm��.,.aaer I� ,I I I Q,,w, �+.wxa�a rw.wern � ' � s O� I�_ O�,g wanma Wriw�wlM O c^sv I '� : I Q,�,M rw�li�tv�ce wwMnan ,O� ��•��uu�nuua.ti..N,.�irr�ra.wav:r.Waen�wA,,:,ac.�.:�, ' 'M.�ew,�a, ra KUONym o�ua[0�*av�rvz'iMNr V�ar�no[4 Vc �� � NB fSTH 35E S ewwn� � � a� mno� N � � .. _, .. . ....... 9B � Un1t 1 wa� Ctavellir�q N8 ISTN 35E a roachaa . ,.._ ._._,... PP--..--:, 9---° . ,c.n. �..�� Lazpentr.�ir �?yo_ in 7}e left 1,ne. 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O1 O1; + . ... .. ..... ....... ........ -�----...: i I Uni[ 3 was travai�in7 NB ISTk 35C appsoachinu �1° � � . .t,zrpenteur Ave�in the lel.t.lane.,..,�civer�._.... .. _. �j ,n�,,; � � , st.ated (COntinuee ai attacnCd paqe) � • .. ....... . . _ _ _____ _.__ o1j � 01 a„�r;.. . .�ri . I wa+w ,+rt�aw�ne» T?p CHEtiST P?lER L LOHMER 256 State Patxol 4460 ����D� D� 0�+�� � I � ,[� +: 7t.f-__-i - ,?'z=.=� I!'i� i� �-, - - -_ i . �. ! �' yC . I - . , i �j'. � � S LOZlL 6/90 �a�eQ pania�a� Ca •144 8280f Cte �r{da :70/8/2014 Ac dint N rraflve,contln ed: !ie as:stap ed ln traR"ic and the front of unit 2 crashed into the rear ot unk 3. ►Jo I junes re repvrted on scene_ Unif 1 was towed t�om fha scene by Rapid Recovery, Unit 9 Is awned by Cily af St. �au. : � i � � � ;� •��,, � +�- inr-,- �� � -".� I�:�i�, l .l - ti�; --�i .. _'.1 ��. - �.i�l_ . ... .. i i 'i i r"i l�✓ .. �r� i �. ._ IJ ��11 f ,��, i _ _ . _�_. I � JjI�F- =i, _ I =I.J.:�_ y �i . . _, . 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